| Item | Confirmed | Notes |
|---|---|---|
| Regular wages/salary up to termination date | ||
| Overtime, bonuses, incentives | ||
| Unused vacation/PTO payout | ||
| Final expense reimbursements | ||
| Other (specify) |
| Item | Confirmed | Notes |
|---|---|---|
| Healthcare coverage end/COBRA info provided | ||
| Retirement/pension plan info provided | ||
| Life/Disability insurance end/transition | ||
| Other benefits (specify) |